There are many aspects of human migration that are still poorly understood, despite advancing globalisation and the greatly enhanced mobility of people made possible by air transport and instant communication technologies. The apparently narrow issue of skills migration is caught up in broader and more complex issues of culture and history. Diversity in context and specific circumstances render the generation of a general theory of human migration difficult, if not impossible, though some have tried.

The author of this little book has given away his conclusion about the particular instance he has studied, by the subtitle 'South African doctors fleeing to Australia'. His survey of over 2000 such doctors (or their reliably informed relatives) has indeed yielded good evidence for a 'push model' of migration, as opposed to the kind of 'pull' model about which the host country is inclined to feel guilty if it is seen to be an active solicitor of well-qualified medical personnel from a developing country much in need of precisely this kind of high-level human capital. One could be forgiven for thinking that the 'active discouragement' measures (such as preventing private practice) set up by the Australian authorities were in fact rather well designed to direct the flow of desperate would-be-migrant medicos to the rural or public vacancies prevalent in that country. Chapter 5 is especially interesting in dealing with contrasting immigration policies in different Australian states, culminating in 2006 in the exclusion of South Africans from the consolidated new recognition system called the 'Competent Authority Pathway' for foreign doctors wishing to register to practice in Australia. It is noteworthy that recent immigrants have in fact been shunted to the remote, under-served areas of the country (Figure 1).

Arnold points out that the enormous (and still increasing) numbers of South African-born Australian residents (from about 23 000 in the 1961 census to 104 000 in that of 2006) represent 'a unique migration', and posits that 'no other English-speaking country has seen, or is likely to see...its professionals (including doctors) emigrating in such numbers' (Figure 2). Over 2000 out of the about 66 000 doctors practising in Australia were born in South Africa. Each emigrating doctor brought along about four or five other people, and many of the movements were planned and executed at extended, rather than nuclear, family level; 'grannies' unfortunately often had to be left at home as a consequence of immigration policy at the receiving country end. The earlier emigrants were mainly White, and often Jewish; their main reason for leaving was the unacceptability of living and working in an authoritarian apartheid state. More recent migrants have included many Afrikaans people and 'people of colour', and have cited crime and urban deterioration as amongst the reasons for their departure. Arnold makes the case that this 'unique' migration was not carried out because of political persecution, or blocked career advancement, or economic hardship. It was a case of lots of people wanting badly to go, and choosing somewhere pleasant to stay and work (they cited 'an attractive lifestyle' and 'family already there' as the top-listed reasons). Arnold sums this up as 'overwhelmingly a flight of non-native peoples [sic] from a country which, for one reason or another, they have come to dislike, perhaps to hate and often to fear'. He continues: 'Few [of the doctors] were attracted to better positions in Australia...they would have emigrated elsewhere had Australia not accepted them.'

The British colonial policy of establishing universities and medical schools in its vast dominions, 'proudly training local students to the same standards as their own students were trained back home', is designated by Arnold as the root cause of the migration problem he has characterised. He contrasts this policy with those of vastly populous Russia, India and China, in each of which he avers the approach to health care was concentrated on the production of lesser trained 'feldschers' and 'barefoot doctors' who are not generally welcome in other countries as migrants, or on training programmes for doctors that were so different from those of the Anglo-Saxon world that professional cross-recognition was difficult or impossible.

The stark fact that an estimated 25% of South African-trained doctors are abroad, while nearly half of Australia's doctors are foreign-born, mostly in countries which have an overall shortage of medical personnel, certainly makes one think. When it comes to policymaking in health education and training, as well as in organising health services generally, we are far from finding satisfactory answers, and yet our ambitious aspiration to 'health for all' dominates the political discourse.

Arnold's book is a thought-provoking and focused analysis of a 'unique migration', but one misses a deeper insight into the themes that have made international migration such a controversial and charged aspect of social and political theory. Thomas Sowell's views on the deeply retentive workings of culture in migrant minorities would surely have merited some discussion, because such minorities frequently play important roles in socio-economic national development.1 Arnold is silent on the fact that no purely voluntary migration, however unique, can escape the moral dimension of who is indebted to whom for life opportunities. Another gap is the more general context of contemporary skills mobility as it affects countries like South Africa and Australia, and the excellent treatment this has received in the case of the former.2

The basic problem with this book is thus that its case-study focus on a 'unique migration' may lessen its value for those who seek to learn from international migrations in general how the immensely important store of high-level human capital can be built and retained within a nation such as South Africa.